This book consists of a collection of my published and unpublished memoirs relating to our lobbying compaign for Kurdish human rights. Written from a personal perspective, it aims to highlight the impact of international politics on events occuring in Kurdistan. The first 470 pages are written in Kurdish and the remaining 130 pages are in English. The book is now available in Hawler and Suleimani bookshops.

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Hello,

I try to read your blog and your articles in Hawlati. Even tho I find it hard to read Kurdish texts, I enjoy your writings. I have two questions regarding this book. Where exactly can I get it and is it written in English?

Dr. Aaron Milstone examines Mohammed Aziz, who endured a mustard gas attack in 1988 in Iraq. He he has been treated at VUMC since 2001. Photo by Dana Johnson

Jessica Pasley

Mohammed Aziz still suffers the effects of a mustard gas attack he endured 15 years ago in his native Iraq. Aziz — who has been treated at Vanderbilt since 2001 — is the first proven case of brochiolitis obliterans seen in the United States after exposure to mustard gas, according to a report in the Aug. 6 Journal of the American Medical Association.

Vanderbilt pulmonary physicians are familiar with bronchiolitis obliterans. Considered relatively rare, the disorder causes scarring and inflammation to the lungs. It is most commonly seen in post lung and bone marrow transplant patients, patients with connective tissue disorders, and can arise after complications from certain forms of viral and bacterial infections.

Aziz was referred to Vanderbilt for a possible lung transplant from an area hospital. He presented with severe shortness of breath, a constant cough and very low oxygen levels. Upon questioning, doctors learned Aziz’s history — he lived in the Kurdish town of Halabja, which was the target of an Iraqi chemical weapons attack that included mustard gas and nerve agents during the Iran-Iraq War.

“This is the first and probably the only time in our clinical practices to see something like this,” Milstone said. “We were mesmerized by his story.

“When I met him two years ago, I thought he had less than a year to live. I am very impressed with how well he has done. His prognosis is difficult. We are hopeful that with supportive care and antibiotics we will be able to keep him stable so that he can maintain a good quality of life and not require transplant for another two to five years.”

Aziz is presently taking high-dose steroids and antibiotics to suppress the inflammation. He agrees that since beginning treatment under Drs. Milstone, Thomason and Rice that his health has greatly improved.

“It’s interesting, when I first came to Nashville, no one would take my illness seriously,” Aziz said through an interpreter, Aram Khoshnaw. “I didn’t get the service I needed until I was really, really sick. It took about six months. Now, I can walk, there is less coughing, my quality of life has improved considerably.”

Aziz, who has no history of smoking or lung problems, describes the day of the attack – which is also documented in the JAMA report.

A student at Baghdad University, he was home visiting his parents. He recalls rushing to the basement of their home for safety.

“We gathered ourselves and tried to escape,” he said. “The children and elders were nauseated, vomiting and blind. But after two hours I had the same side effects. I lost my [eyesight] for almost a month. Led by friends about six kilometers (4 miles), I escaped. It was horrible going through the Iran border hearing death, people falling, people dying along the way.”

Within hours of the attack, 15 family members were dead. A reported 5,000 people died the day of the attack and up to 12,000 died in the days following.

Aziz was taken to New York for treatment through the Red Crescent Service of Iran, where he later returned to live in a refugee camp. In 1991 he returned home to Halabja to help rebuild the town.

In 1998 he left for Syria, where he spent two years awaiting immigration status. He was resettled in Nashville in 2000.

Although Aziz is the first documented case of BO as a direct result of chemical warfare, Vanderbilt physicians assume that this condition exists in other Kurds living in Halabja — but no cases have yet been reported in the U.S.

“Because Mr. Aziz says his parents, who remain in Halabja, have similar but less severe problems, we feel certain that other case exist.” Thomason said. “Of course, it is extremely difficult for these patients to gain access to a facility such as Vanderbilt in order to obtain a comprehensive evaluation and treatment plan,” he said. “This is the first time we have had the privilege of caring for such a patient.”

Milstone said this case has been a real eye-opener and shows just how little the U.S. knows about bioterrorism.

“It does happen. It’s out there. It just hasn’t happened here.”The recommendation from the report is that “BO from toxic fume inhalation can occur after mustard gas exposure and should be considered in patients who have compatible clinical presentations.”

Bronchiolitis Obliterans in a Survivor of a Chemical Weapons Attack To the Editor: Bronchiolitis obliterans develops when an injury of small conducting airways leads to the proliferation of granulation tissue and obliteration of the airway lumen. The histological pattern is nonspecific and can result from multiple etiologies. The clinical presentation is divided into 5 categories: toxic fume inhalation, postinfectious, connective tissue disease–associated, localized, and idiopathic.1 Several substances have been reported to cause bronchiolitis obliterans through inhalation of toxic fumes. The distribution of these agents in the lung is determined by the size of the molecule, the duration of exposure, and the solubility of the agent.2

The inhalation of mustard gas has been reported to cause chronic bronchitis, airway hyperactivity, bronchiectasis, and pulmonary fibrosis,3-6 but there are no reports of the occurrence of bronchiolitis obliterans. We report a patient with confirmed bronchiolitis obliterans several years after likely exposure to mustard gas in Iraq.

Report of a Case

In August 2001, we evaluated a 37-year-old male Iraqi Kurd for possible lung transplantation. He reported that he had been present on March 16, 1988, when Iraqi fighter jets dropped multiple warheads on the northeastern Iraqi city of Halabja. (The Halabja attack has been extensively documented elsewhere.7-8) He and his family initially feared direct physical harm and fled to the basement of their home, but oppressive heat and poor air circulation forced them from this enclosed space. As they ran outside, the patient noted a noxious odor similar to rotten fruit. He reported that the intense smell lasted for 5 hours, during which time 15 members of the patient's family died on the street.

Six hours after his initial exposure, our patient reported experiencing eye pain, copious tearing, cough, and dyspnea. He then developed complete blindness, a condition that lasted for 20 days. The Red Crescent service of Iran transported him to the United States for ophthalmologic care and he recovered with treatment (records unavailable). His cough, dyspnea, and production of sputum progressed over the next 14 years, eventually limiting his ability to perform activities of daily living. The patient reported that his parents also complain of similar but less severe lung-related symptoms, including the daily production of purulent sputum. Neither the patient nor any members of his family have any history of tobacco use. He denied having had a history of pneumonia or significant occupational or environmental exposures before 1988.

View larger version (76K):[in this window][in a new window] Figure 2. Computed Tomography Scan of the Chest of Patient With Bronchiolitis ObliteransScan performed using intravenous contrast demonstrates a ground-glass, mosaic pattern with sharply demarcated borders and surrounding hypodense pulmonary parenchyma, consistent with small airway disease.

Treatment included high doses of prednisone (1 mg/kg of body weight) for 6 months, followed by tapering to his current dose of 10 mg/d.9 His symptoms have substantially improved, his spirometry remains stable, and he has not yet required listing for lung transplantation.

Comment

Investigations have revealed that mustard gas and the nerve gases sarin, VX, and Tabun were used in the Halabja attack.7-8 Mustard gas is a vesicant that damages cells through alkylation of DNA and through a secondary, cytokine-mediated inflammatory response.10 This occurs at areas of contact between the gas and human tissue (ie, the eyes and respiratory tract). Eye pain, excessive lacrimation, and blindness occur within 1 to 12 hours of exposure, while edema of the tracheobronchial tree occurs between 4 and 12 hours. High concentrations induce pseudomembranous changes in the airways, and may result in airway necrosis. The clinical course is frequently complicated by secondary bacterial pneumonias. Our patient's initial ophthalmic and ongoing pulmonary symptoms are consistent with exposure to a vesicant such as mustard gas.

The majority of medical reports regarding exposure to mustard gas describe the respiratory symptoms of soldiers involved in various military conflicts, including World War I and the Iran-Iraq war.3-4,6 None of these reports, however, has described bronchiolitis obliterans resulting from exposure to mustard gas or among civilian populations specifically targeted by chemical warfare. We suggest that bronchiolitis obliterans should be considered in patients with respiratory symptoms who have a history of possible exposure to mustard gas.